Abruptio placenta vld
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obstetricians, postgraduates, undergraduates, abruption of placenta, bleeding
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Abruptio placenta vld
- 1. ABRUPTIO PLACENTAEABRUPTIO PLACENTAE • DR V L DESHMUKH • ASSO PROF • DEPT OBGY • GMCH A,BAD
- 2. Abruptio PlacentaeAbruptio Placentae • Abruptio – tearing away from • Placentae – placenta • It is a Latin word
- 3. SynonymsSynonyms • Accidental Haemorrhage (Great Britain) • Ablatio Placentae • Premature separation of placenta Definition: • It is one form of Antepartum Haemorrhage where bleeding occurs due to premature separation of normally situated placenta.
- 4. a) Retreoplacental haematomo b) Revealed c) Concealed d) Mixed
- 5. 1. Revealed : Most common Blood loss is visible as the blood drops down between membrane & decidua & come out through cervical canal. 2. Concealed : Rare a) Effusion of blood behind the placenta but its margins still remain adherent b) Placenta completely separated but membranes intact
- 6. c) Blood enter amniotic sac after breaking membranes d) Fetal Head closely applied to lower uterine segment. 1. Mixed – quite common - Some amount of blood is inside & some expelled. Incidence - 1 in 150 deliveries
- 7. • Perinatal mortality – 15 – 20% • Maternal mortality – 2 – 5 % Etiology: a) Maternal Hypertension: 44% of all cases mechanism- Spasm of vessels in utero placental bed i.e. of decidual spiral artery causes endothelial damage & rupture of vessels leading to haemorrhage.
- 9. b) Maternal trauma – 1.5 – 9.5 % - Motor vehicle accidents (MVA) - Assaults, falls. c) Foetal trauma – - Attempted external cephalic version - Needle puncture at amniocentesis d) Cigarette Smoking – - Decidual necrosis
- 10. e) Cocaine abuse – Onset of labour with placental abruption in 4 of 23 women immediately after IV self infection of cocaine. f) Short umbilical cord – Mechanical pull during labour. g) Sudden Uterine decompression 1. Delivery of first baby of twins 2. PROM 3. Sudden escape of liquor amni in hydramnios.
- 11. h) Advanced Maternal age i) Thrombophilias j) Folic acid deficiency k) Sick placenta l) Retroplacental fibromyoma m) Idiopathic n) Recurrence increase 10 fold.
- 12. Pathogenesis: • Initiated by Haemorrhage into decidua basalis. • The decidua splits leaving thin layer adherent to the myometrium • Subsequently there is development of decidual Haematoma that leads to separation compression & ultimate destruction of placenta. • Sometimes
- 13. – Decidual spiral artery rupture RP Haematoma separation of placenta inability of uterus to contract& control the torn vessels. – Changes in other organs • Liver – Fibrin knots • Kidney – Acute cortical necrosis or acute tubular necrosis, proteinurea. • Blood coagulopathy – Due to excess consumption of plasma fibrinogen due DIC & RP bleeding.
- 14. Investigation : • For evaluation of haemostatic system in patients with abruptio placentae, most laboratories use DIC profile. • It includes
- 15. Test Normal Results Fibrinogen 150 to 600 mg/dl PT 11 to 16 sec. PTT 22 to 37 sec. Platelet count 120000 to 350,000/mm3 D-dimer <0.5mg / L FDP < 10 mg / dl Bleedin time (Duke) 1-3 mins (IVY’s) 1 – 9 mins Coagulation time (wright tube) 3 – 7 mins (Lee & White) 4 – 9 mins.
- 16. • Clot observation test (weiner) – 5 ml of venous blood placed in 15 ml dry test tube & kept at 370 C – CT < 6min, fibrinogen level > 150 mg% no clot < 30 min,fibrinogen level < 100 mg % • FDP – Latex agglutination test – In DIC > 80 ug / ml
- 17. • D-dimer – Specific component of fibrin break down – Latex agglutination method. – In DIC > 200 mg / L • Estimation of fibrinogen – Blood sample collected in EDTA vial critical level 100 mg %
- 18. Diagnosis of abruptio placentae is more clinicalDiagnosis of abruptio placentae is more clinical rather than USG findings.rather than USG findings. S/S Frequency Vaginal bleeding 78% Uterine tenderness /back pain 66% Fetal distress 60% High frequency contractions 17% Hypertonus 17% Idiopathic preterm labour 22% Dead fetus 15%
- 20. • Classification of placental abruption is based on extent of separation (ie, partial vs complete) and location of separation (ie, marginal vs central). Clinical characteristics include the following: Class 0 is asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
- 21. Class 1 is mild and represents approximately 48% of all cases. Characteristics include the following: • No vaginal bleeding to mild vaginal bleeding • Slightly tender uterus • Normal maternal BP and heart rate • No coagulopathy • No fetal distress
- 22. Class 2 is moderate and represents approximately 27% of all cases Characteristics include the following: • No vaginal bleeding to moderate vaginal Bleeding • Moderate-to-severe uterine tenderness with possible tetanic contractions • Maternal tachycardia with orthostatic changes in BP and heart rate • Fetal distress • Hypofibrinogenemia (ie, 50-250 mg/dL)
- 23. Class 3 is severe and represents approximately 24% of all cases. Characteristics include the following: • No vaginal bleeding to heavy vaginal bleeding • Very painful tetanic uterus • Maternal shock • Hypofibrinogenemia (ie, <150 mg/dL) • Coagulopathy • Fetal death
- 24. • Role of USG in Abruptio placentae – – locate RP clot (20-25%) • Estimation of blood loss – Wt. of RP clot in gm x 3 • Pain due to RP clot causing intravasation of blood & disruption of myometrial fibres.
- 25. • Couvelaire uterus (Uteroplacental apoplexy)
- 26. Microscopic appearance • Due to more severe & wide spread extravasation of blood into the uterine musculature & beneath the uterine serosa. • Occasionally seen beneath the tubal serosa, connective tissue of broad ligament, substance of ovaries & in peritoneal cavity
- 27. • Incidence (unpredictable) • Myometrial Haemotomas seldom interfere with uterine contractions to cause PPH. • Hence not indication for hysterectomy. • Naked eye appearance uterus of dark port wine colour.